What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (35 page)

This contrast becomes sharper when you consider some of AA’s famous twelve steps. Step one, for instance, has the alcoholic “powerless” before his disease. The disease is genetic and beyond his control. Only by relinquishing control to a “higher power” can recovery take place. The disease is always there, rendering him ever susceptible to relapse.

This framework cuts both ways. On the one hand, powerlessness is sometimes the stuff of religious conversion. The dark night of the soul can steel people to quit drinking in the face of enormous temptation and stick with this decision. On the other hand, a belief in powerlessness tends to undo the main virtue of the disease view, which is to move people out of sloth toward trying to change themselves. A sense of powerlessness often leads to passivity, helplessness, and hopelessness.

Is There an Addictive Personality?

Alcoholics are depressed, anxious, dependent, oral, filled with self-doubts and self-loathing, and they harbor a sense of inferiority. They are also pessimistic, self-defeating, paranoid, aggressive, and psychopathic, to name just a few of their worst personality characteristics. These facts have led investigators to claim that there is an addictive personality: some constellation of these traits. This means that people with such personalities are easy targets for addictive substances or behaviors. Take away the alcohol, and they will turn to crack, to sex, to gambling, or to cigarettes. It also implies that such people turn to alcohol to numb their emotional torments. You may be worried that you or someone close to you—displaying this constellation—is at risk.

This is a matter that has been dealt with definitively, though it took many years of work and a major methodological advance: long-term studies of the life span of alcoholics—prospective, “longitudinal” studies. The idea of an addictive personality is rooted in looking at alcoholics for only a short time, say a year, or even five years. When this is done, you see many of these so-called addictive traits. But it is absolutely crucial that these people are studied while they are abusing alcohol. Which comes first, the addictive traits or the abuse of alcohol? It could be that watching helplessly as alcohol destroys your life brings about anxiety, depression, crime, dependency, pessimism, inferiority feelings. Alternatively, it might also be that these traits bring about alcoholism.

Two landmark studies have looked at groups of men
⁶
over a period of forty or more years: from childhood—before any alcoholism—until late middle age. Both have been conducted by George Vaillant, a Harvard researcher, and my candidate for the most important psychoanalyst since Freud. In one study, the Harvard classes of 1939–44 were combed for their healthiest members. Five percent were chosen on the basis of extraordinarily good physical and mental health, as well as intellectual prowess. As undergraduates they were endlessly interviewed and took scores of psychological tests. These men have since been followed closely to this very day. Of the 252 men, 30 became abusers of alcohol. Vaillant asked how these 30 men differed, before they became alcoholic, from the other 222 men.

Before I report what he found, I want to mention his second study, whose subjects came from the opposite end of the American spectrum of opportunity: Boston’s inner city. These men, too, were followed for forty years. Seventy-one of them became alcoholic; 260 did not. Again, Vaillant asked how the alcoholics differed from the rest before their alcoholism.

The results of the two studies were identical. There is no sign of an alcoholic personality. The men who became alcoholics differed in only two ways from the men who did not: They had more alcoholic relatives and they were more likely to be Northern European (particularly Irish). Emotional insecurity, depression, dependence, criminality while young, and the rest of the addictive panoply (in the absence of alcoholic parents) did not predict alcoholism.
⁷

These results are a breath of fresh air. Before Vaillant’s discovery, clinicians who looked at alcoholics only during the disease felt free to make such alarmist pronouncements as “The development of the disease process of alcoholism is inconceivable without underlying psychopathology.”
⁸
Vaillant’s discovery is that such pronouncements are simply wrong: It is alcoholism that produces the traits of depression, dependence, criminality, and so on. The only thing alcoholics have in common prior to their alcoholism is a dangerous susceptibility to alcohol, not underlying bad character or mental illness that merely displays itself in the guise of drunkenness.

The good news is that once alcohol abuse ends, so do these undesirable traits. The recovered alcoholic is no more depressive, psychopathic, pessimistic, or selfish than any of the rest of us. Since he may have missed two decades of his life, however, he is often less grown up in work, in emotional life, and in relationships than other men his age. As my closest childhood friend told me after recovering from twenty-five years of drug abuse, “Marty, I’m fifty going on twenty-five.”

Is Alcoholism Progressive?

It is a central tenet of AA that alcoholism is not only a disease but a
progressive
disease. Like syphilis, which unchecked progresses from a sore on the penis to weakness of the limbs to insanity to death, alcoholism unchecked progresses from social tippling to abuse to addiction to death. Once someone genetically inclined to be alcoholic starts abusing alcohol, there can be only one of two outcomes: death from alcoholism or total abstinence. Is this picture true?

There is one sense in which alcoholism is certainly progressive. Alcohol produces
tolerance
—you need more and more of it to give you the same high. Tolerance, along with withdrawal—the craving that abstinence produces—is what it means to have an addiction. When someone claims that alcohol or heroin produces a physical addiction, they are wrong if they believe that there is some known chemical or biological pathology. Rather, “physical” addiction is a misnomer. All it refers to are
behavioral
facts: It takes more and more of the substance to work, and if you stop taking it, you will suffer withdrawal.
⁹

But needing more and more alcohol is not what AA means by the claim that alcoholism is progressive. This claim means that the symptoms get worse with more alcohol. First come blackouts and frequent intoxication, then arrests, complaints from friends and relatives, and morning drinking. This is followed by repeated failures to stop drinking. Then come job loss and benders. Finally, after three to ten years, come convulsions, hospital treatment, and AA. This ends either with successful abstinence or with death.
¹⁰

The same landmark study that answered the question of whether there is an addictive personality tells us whether alcoholism is progressive. Because the study provides an entire lifetime picture of the alcoholic—before, during, and after (if there is an after)—it maps out the whole course of alcoholism.

Here, AA gets it mostly right. Alcoholism is not inevitably progressive, but it usually is. Of the no inner-city alcoholics looked at over forty years, 73 followed a progressive course ending either in abstinence (about half) or extreme abuse and death (the other half). The remaining 3 7 did not show a progressive disease. These men recovered from alcoholism to social drinking or periodic heavy drinking without much in the way of adverse symptoms.

Vaillant has just obtained the fifty-year follow-up of these men. He now paints an even more complete picture: Early in life, alcoholism progresses. Drinking gets heavier and heavier from age 18 to age 30 to age 40. Then it begins to stabilize. Few alcoholics are worse at age 65 than they were at age 45. Middle age, if you manage to live that long, is usually self-correcting. Crime, obesity, schizophrenia, manic-depression, and alcoholism all tend to burn out in middle age. Vaillant states a “One-Third” rule for alcoholism: By age 65, one-third are dead or in awful shape, one-third are abstinent or drinking socially, and one-third are still trying to quit.
¹¹

Can you tell in advance if an alcoholic is headed for the progressive course or the rarer nonprogressive course? Those men headed for the progressive disease had the worst symptoms once they started drinking, they smoked more (two packs a day), and they spent more years feeling “out of control” of their drinking (fifteen versus four years).

Recovery

• What are your chances of recovering from alcoholism?
  

• Does treatment work?
  

• Does AA work?
  

These are very difficult questions to answer. I know of no other area of treatment research in which so much money has been spent and so little has been accomplished. To my mind, the lack of knowledge is a scandal. The right way to determine if treatment X (say, AA or a medication or an inpatient program) works is simple, in principle. Give a group of alcoholics treatment X. Give a control group, matched for factors relevant to recovery (like employment, emotional stability, severity, and social class), everything except treatment X. Then wait and see who shows a better outcome. This has been done for most of the problems we have looked at in this book. It has not been done for alcoholism.

There is one obstacle to good outcome studies of alcoholism: Researchers are dealing with a problem in which a cycle of recovery and relapse is repeated for years in its natural history. Illumination as to why relapse is so common begins with what does
not
protect you against relapse. George Vaillant, for instance, compared the childhoods of those alcoholics who relapsed time and again with the childhoods of those who became securely abstinent. All of the following do not predict who will become securely abstinent:

• good mothering
  

• high boyhood competence
  

• not coming from a multiproblem family
  

• high IQ
  

• good education
  

• no family alcoholism
  

This should shock those of you who believe in the importance of childhood experience (
chapter 14
will shake your belief in this dogma further).

So many factors that seem to protect people against devastation by other psychological troubles fail to protect people against alcoholism because this problem, unlike other diseases, destroys three of the most important factors that facilitate recovery from any disease: ego strength, willpower, and social support. Alcohol damages the brain: Strong people with tenacious willpower are rendered weak and pliant. Alcohol renders “kings and geniuses no different from paupers and imbeciles.” It is the “great leveler of human differences.” Further, alcohol systematically destroys your loves and friendships. It robs you of social support by rendering you selfish, irresponsible, and out of control over anger and sadness. Without friends and family, the sufferers of any chronic disease have a worse course.
¹²

If all these childhood factors fail to make recovery more likely, what succeeds? First, the fewer symptoms you have on the alcoholism quiz, the more likely it is that you will recover. After that, being married, having a job, being middle-aged, being well-educated, being white, and being middle-class all predict recovery. In short, social stability helps enormously. People who are in this category, rather than the “skid row” category, have twice the chance of recovering.
¹³

Paradoxically, extreme severity helps recovery as well. When people are very badly threatened—with death, disfigurement, bankruptcy—they are ripe for conversion. Hitting bottom can, unmistakably, be a powerful force for dramatic change and recovery. Having a middling case of alcoholism, being a “heavy drinker,” has the worst outcome. It is not mild enough to make recovery easy and not extreme enough to threaten life, family, and livelihood so shockingly as to jolt you into abstinence. Vaillant’s Harvard men who were moderately alcoholic at forty still are as they enter old age. The mild cases and the extreme cases do better.
¹⁴

What are the overall chances of recovery from severe alcoholism in the natural course of events? First, one major caveat: The chronic relapses of alcoholism mean that when researchers look for only a short time—say, for six months after any treatment—they will see a rosy picture. Perhaps as many as 65 percent of people treated are on the wagon for this long after treatment. Every alcoholic has gone on the wagon time and again. Trying to give it up and repeatedly failing is part of what it means to be alcoholic. But the real picture starts to emerge after a minimum of eighteen months. Studies that reveal true chances of recovery from alcoholism are the few very long-term studies.

Here are some representative statistics: Of no alcoholic men from the inner city whom George Vaillant followed for their lifetime, 49 (45 percent) became abstinent for at least a year. Of these 49, 21 (19 percent) became securely abstinent—on the wagon for at least three years. Of 100 clinically treated alcoholics Vaillant followed for twelve years after hospital discharge, 25 percent were stably abstinent, 21 percent were uncertain, 3 7 percent were dead, and 17 percent were still alcohol-dependent. Similar percentages emerge from a ten-year follow-up of British alcoholics. So the best estimates I can venture about the long-term chances of recovery from alcoholism are:
¹⁵

• A substantial minority of alcoholics recover.
  

• About one in five will recover completely.
  

• About half will die prematurely or remain alcohol-dependent.
  

• Socially stable alcoholics have about double the chances of recovery.
  

• Very severe and very mild symptoms most suggest recovery.